<p>Azathioprine (AZA), a prodrug of 6 mercaptopurine, is an immunosuppressant that can be used as adjunctive therapy with corticosteroids in the treatment of arteritic form of ischemic optic neuropathy. Although myelotoxicity is known to occur while using azathioprine, severe pancytopenia is rarely seen. Patients with thiopurine methyltransferase (TPMT) deficiency are at high risk of developing severe myelosuppression. A 63 year* old female with ischemic optic neuropathy was initiated treatment with oral methylprednisone. As two courses of oral steroids showed no significant improvement, oral azathioprine 25 mg twice daily was added and gradually increased to 50 mg twice daily with relief of symptoms. 6 mo later, she was admitted with acute stroke and lab reports showed low levels of total blood counts or pancytopenia. The patient was put on broad spectrum antibiotics; given injection of granulocyte colony stimulating factor 300 mcg subcutaneously and blood transfusion as correction till counts normalised. She improved over 14 d and on next follow-up counts were in normal range. Causality was assessed by Naranjo causality assessment scale and a probable relationship was obtained between azathioprine and pancytopenia with a score of 6. Variations in TPMT activity occurs due to genetic polymorphism. Physicians should be aware of the possibility of myelosuppression while prescribing azathioprine. Frequent blood count monitoring is the most convenient way to avoid this problem where testing for TPMT deficiency is not possible.</p>
Background & objectives:Tyrosine kinase inhibitors (TKIs) targeting the epidermal growth factor receptor (EGFR) have been evaluated in patients with advanced non-small cell lung cancer (NSCLC). Erlotinib and gefitinib are the first-generation EGFR-TKIs for patients with NSCLC. However, there is a paucity of studies comparing the effectiveness of these two drugs. Hence, this study was aimed to compare the effectiveness and safety of erlotinib and gefitinib in NSCLC patients.Methods:This study included 71 NSCLC patients who received EGFR-TKIs between 2013 and 2016. Adverse drug reaction of both erlotinib (n=37) and gefitinib (n=34) was determined and graded according to Common Terminology Criteria for Adverse Events grading system. Effectiveness was measured using response evaluation criteria in solid tumours and progression-free survival (PFS). Pharmacoeconomic analysis was performed by cost-effective analysis.Results:When comparing safety profile, both the drugs had similar adverse events except for dermal side effects such as acneiform eruption (51.4%), rash (54.05%) and mucositis (59.5%) for erlotinib and 20.6, 26.5 and 29.4 per cent for gefitinib, respectively. The PFS of the two drugs was compared to differentiate the effectiveness of erlotinib and gefitinib. There was no significant difference between the effectiveness of the two drugs. The pharmacoeconomic analysis showed that gefitinib was more cost-effective than erlotinib.Interpretation & conclusions:This study showed that erlotinib and gefitinib had similar effectiveness but gefitinib had a better safety profile compared to erlotinib. Therefore, gefitinib could be considered a better option for NSCLC patients compared to erlotinib. However, further studies need to be done with a large sample to confirm these findings.
Objective: To report a case of lithium induced bilateral nonpitting pedal edema. Methods:The clinical data of a bipolar affective disorder patient with current episode of mania and psychotic symptoms who experienced bilateral non pitting pedal edema with lithium. Results:The patient was a 29 yr old female who developed bilateral non-pitting type pedal edema with lithium therapy with normal plasma lithium level (0.72mEq/l). She is a known case of bipolar affective disorder (BPAD) was admitted to psychiatry department with episode of mania with psychotic symptoms. She had history of drug induced hypersensitivity reaction with eosinophilia and systemic symptoms (DRESS) with oxcarbazepine and so the drug was discontinued and was started on tablet lithium 400 mg twice daily. On admission here, the dose of lithium was increased to 1200 mg/day. The patient gradually improved but she developed bilateral non-pitting pedal edema. Serum lithium concentration was normal and there were no other early symptoms of lithium toxicity. But as the patient's distress further increased with increasing pedal edema, it was decided to stop lithium altogether and to maintain the patient on tablet quetiapine 800 mg therapy for BPAD. Within one week of stopping lithium the edema on both her feet decreased significantly. Causality was assessed by naranjo causality assessment scale and a probable relationship was obtained between lithium and pedal edema with a score of 6. Conclusion:This case emphasises that regular physical examination and laboratory investigations are important for patients who are on lithium therapy. Clinicians should always be careful while initiating lithium treatment in a patient with respect to the initial dose and dose escalation even after a period of successful therapy with lithium, as minor dose escalation can cause major changes in the serum lithium concentration and thereby the patient's tolerability to lithium.
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